术中放疗、术后全乳放疗在早期乳腺癌保乳治疗中的意义

Significance of intraoperative radiotherapy and postoperative whole-breast radiotherapy in breast-conserving therapy for early breast cancer

目的:探讨术中放疗(intraoperative radiotherapy,IORT)、术后全乳腺放疗(whole-breast radiotherapy,WBRT)在早期乳腺癌保乳治疗中的意义。方法:选择有保乳意愿、原发灶直径≤40 mm的T1-2N0-1M0期乳腺癌患者149例,按放疗方式分为术中放疗组(n=52)、术中放疗+全乳放疗组(n=43)和全乳放疗组(n=54)。保乳手术予肿瘤外5~10 mm扩大切除,对明确的前哨淋巴结予以活检术和(或)腋窝淋巴结进行清扫处理。IORT剂量15.0~21.0 GY,中位剂量18.0 GY。WBRT剂量50.0 GY/25次。结果:术中放疗组、术中放疗+全乳放疗组与术后全乳放疗组5年生存率分别为100.0%、94.4%、100.0%(χ^2=2.40,P=0.301);5年局部控制率分别为100.0%、100.0%、94.9%(χ^2=3.17,P=0.142);5年无远转生存率分别为100.0%、82.2%、86.0%(χ^2=7.59,P=0.022)。Cox多因素分析提示,T分期是影响患者预后的临床因素(χ^2=4.71,P=0.030)。术中放疗+全乳放疗组皮肤、脂肪坏死发生率为9.3%(4/43),仅术中放疗组未出现肺组织晚反应放射性损伤。结论:对原发灶直径≤40 mm的T1-2N0-1M0期保乳患者采用IORT,在局部控制率、并发症方面均显示出明显优势,可以替代WBRT。但不建议采用术中放疗联合术后全乳腺照射的治疗策略。

Objective:To explore the significance of intraoperative radiotherapy(IORT)and postoperative whole-breast radiotherapy(WBRT)in breast-conserving therapy for early breast cancer.Methods:A total of 149 patients with T1-2N0-1M0 breast cancer who had the intention to preserve breast,and whose primary lesion diameter≤40 mm were selected.All patients were divided into three groups by postoperative radiotherapy type:52 cases were treated with IORT(IORT group),43 cases were treated with IORT+WBRT(IORT+WBRT group),and 54 cases were treated with WBRT(WBRT group).Breast-conserving therapy was performed for extended resection in the range of 5-10 mm of the tumor,with biopsy of confirmed sentinel lymph nodes and(or)dissection of axillary lymph nodes.The IORT ranged between 15.0 and 21.0 GY,with a median of 18.0 GY.WBRT with a total dose of 50.0 GY/25 fractions.Results:The 5-year survival rate of the IORT group,IORT+WBRT group and WBRT group was 100.0%,94.4% and 100.0%,respectively(χ^2=2.40,P=0.301).The 5-year local control rate was 100.0%,100.0% and 94.9%,respectively(χ^2=3.17,P=0.142).The no distant metastatic survival rate was 100.0%,82.2% and 86.0%,respectively(χ^2=7.59,P=0.022).Cox multivariate analysis showed that T stage was a significant clinical factor affecting the prognosis of patients(χ^2=4.71,P=0.030).Severe skin disease and fat necrosis were occurred in the IORT+WBRT group,with incidence of 9.3%(4/43).No late radiation damage in the lung tissue was observed in the IORT group.Conclusion:IORT has advantages in local control rate and complications for patients with T1-2N0-1M0 breast cancer and primary lesions diameter≤40 mm.The treatment strategy of IORT combined with postoperative WBRT is not recommended.